Provider Demographics
NPI:1164177572
Name:DOUGHERTY, ABIGAIL MAE (PA-C)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:MAE
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4077 S CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4077 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9513
Practice Address - Country:US
Practice Address - Phone:269-429-2992
Practice Address - Fax:269-429-3372
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007476RX363A00000X
MI5601012437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant